 What is up guys Karma medic here and welcome back to another dose. My name is Nasser and I'm a doctor living and working in London. In today's video we're going to be talking about my rotation on vascular surgery which was my second ever job as a doctor. I'm going to be diving into what the rotation was like, the things that I particularly enjoyed, things I didn't like so much, what a typical working days like, on calls nights, the team, the workload, patient caseload, etc. So let's just get into it. So our typical day in vascular surgery was from 8 o'clock in the morning until 6 p.m. in the afternoon. So that's already a 10-hour working day as the completely normal base standard. So if you're working one day to Friday, your normal shifts, you'll be working a 50-hour work week, which is already quite a significant bump up from the geriatrics placement that I talked about in my previous video, link up over here to watch after this one. So I showed up to the doctor's office at 8 o'clock in the morning and from 8 to 8 30, all we would do is prepare the list for the day. So this was an extremely archaic, out-of-date way of preparing a piece of paper list with all the patient details on it that we could give to our seniors so that we could know who all the patients are that we need to see, what's going on with them, what has happened with them, and what we need to do. Now the problem with this list was that it needed to be manually updated. So every day in the morning, the juniors, the F1s, like myself, we would sit down and manually update patient locations where they had moved to, what investigations had been done for them and what planned surgeries and things were needed for them every single day, which is really just an absolute waste of time. This should be something that is organized on the computer that integrates and takes information from the already existing electronic system that we have, updating the patient locations and if they've been discharged or not and where they are. I mean, just having to manually update it was such a hassle and something that was, you know, so secretarial and administrative. And we had to do that every single day from 8 to 8.30 and then print out that list and go to handover. Now this list at the best of times throughout my four month rotation would have maybe 40 patients on it, but at the worst of times would have 60 and 70 plus patients on it. So it was a huge task just updating it for 70 individual patients and coming from my previous rotation on geriatrics where we had about 30 patients on the entire ward, this was a huge jump up. Now, another big difference between my previous rotation and this one is that on the previous rotation, I was the only F1 around. So I was the most junior person on the team and I was the only one of that level as an F1 junior doctor. Whereas now on vascular surgery, there were four of us and if we were lucky on some days, we'd have even five. And so there was this really nice sense of community and camaraderie amongst the F1s. We were all kind of going through the same thing. We understood each other's struggles and problems and we helped each other out in a really great way, which I'll get on to later on in the video as well on this placement, given that it was a surgical rotation right off the bat. I let all of the seniors know that I'm an aspiring surgeon. I'm very interested in surgery and absolutely any opportunity I could get to go down to theater to scrub in and help out in surgeries I would absolutely love to do, which I'm very glad that I did early on because I think that opened up a lot of opportunity for me to go into theater throughout the rotation and have honestly some of the best times of my life in my working life as a doctor so far. And then 8.30 until about 9.30, 10, we would have the MDT meeting and handover. So the MDT meeting is a meeting with all of the consultants on vascular surgery, all of the registrars, all of the juniors as well, like myself, and they would discuss cases that needed the opinion of multiple different surgeons. So this would often involve looking at a patient's scans, talking about their history and what has worked in the past and what hasn't, and deciding what the best course of action is moving forward, whether that be conservative management, where we say we don't think we should do anything for this patient, or they should have X or Y surgery or X or Y medical management. After that, the night team, the registrars who were working overnight, they would hand over all of the admissions that came in during the night. So for example, this patient came into A&E with X, Y and Z, they've now moved to the ward in bed number five, and we need to go see them and do blah, blah, blah, blah. And up until this point, the juniors like myself, we were just watching, listening and trying to learn from the conversations that were going on. But then after that, it was time for the actual handover, which is where we became involved. Now the actual handover involved going through every single patient that we had on that piece of paper that we had just prepared and talking about what's new for them, what's outstanding for them and what we need to do today. And honestly, just given the number of patients that there were and sometimes their complexity, this would last for a very long time. In the worst case scenarios, we would finish this morning meeting at about 10 30, which is really late into the day given that normally ward rounds start at about nine in the morning. So we've already lost an hour and a half of our day to just doing this handover. And after this, we would split into two major groups. So there was the diabetic foot round group and the surgeon of the week group. The diabetic foot round group involves any patients who have diabetes and generally had some sort of complication or issue or disease process involving their feet. And then surgeon of the week was pretty much everything and everyone else. If we were well staffed enough. So if we had four or maybe five juniors present that day, then we would have one person who was designated the float. Now the job of the float was to hold the bleep, which is that little plastic thing that beeps nonstop throughout the day and gives you lots of jobs to do. And they would be responsible for taking care of all of those calls as well as helping out with the warground to do any urgent jobs that came up. So for example, if we're on the warground and we see that a patient is due for surgery later today, but they haven't had a group and save and a clotting taken, which are two blood tests that you need before a patient goes to surgery, the float would be responsible for going to take those bloods and make sure that they're done in time. On top of that, if we see a patient and we think they need an urgent scan. So let's say they need an ultrasound Doppler of one of their limbs to assess the blood flow going down to their peripheries, then they would be responsible for calling and making sure that happens as soon as possible. So if you're lucky enough to be well staffed and have a float as part of your day, then your day has instantly become so much better because that float can start working on the jobs whilst you're doing the warground throughout the day. The other scenario is that you finish warground at two, three, four PM and then you start doing all the jobs that you've accumulated throughout the day. And oftentimes with that many patients and starting so late, it's just impossible to get everything done by six PM. And all the other specialties who you may need help with have already got their lists full and their schedules for the day, so they can't really come do something urgent to help you out. So just having a float is amazing. Okay, so let's talk about the bleep. Honestly, I very love hate relationship with this thing. I've talked about it before, but a brief recap, if you're unfamiliar, it's this small little plastic device, which people use to call you when they want you. So when someone wants to contact the vascular surgery F one, they go on this app called induction and they search what is the number for vascular surgery F one. And let's say it's one, two, three, four, they dial one, two, three, four into their computer. And then it rings me on that little plastic thing. I see that they've called from five, six, seven, eight, I go to a computer and dial five, six, seven, eight, and they pick up the phone. Now there's a few difficult things about the bleep. Generally, one of them is that you don't know the level of emergency that's coming through the phone on the other side. So if someone calls me, they could be saying, Hey, could you please prescribe some insulin for this patient? Or Hey, you prescribed 10 milligrams of allotipine instead of five. Can you please change it? Which is a completely non-emergency thing which I can write down on my list and do at a later time. Or they could be calling you and saying, one of your patients is in cardiac arrest. Can you please come here immediately? When you receive the call, there's no way of knowing what level of seriousness or significance is coming through that phone. Typically, if someone bleeps me two times from the same number within a short period of time, so one minute, two minutes, three minutes, up to five minutes, if I receive two bleeps from the same number in a short period of time, I assume it is something urgent and I get to the phone immediately to see what's going on. And a lot of the time this is true. If someone tries to bleep me and I don't respond because I'm busy, they'll usually bleep me back in 15 minutes, 20 minutes, half an hour. And that's completely reasonable if it's something non-emergency. But if it is emergency and they need to contact me now and I don't call them back within a minute, it's reasonable for them to bleep me again because they need to contact me immediately. Now a lot of the time people don't understand this sort of etiquette or rule about using the bleep and I would often get bleeps two or three times within a five or 10 minute period. I would assume there's some sort of emergency going on, rush to the phone to call them back and then it would be something like, hey, can you change the medication for this patient or hey, can you do x, y, or z, which is completely non-emergency. And I found that to be particularly frustrating and I found myself having to say over and over again, hey, in the future, if you bleep me within a short period of time, I'm going to assume it's an emergency. So please give me 10 minutes or 15 minutes to get back to you if it's not an emergency because I'm busy doing something else. I just wish that more people understood this bleep etiquette so that it would help me triage what the emergency is that's coming through the phone. Because a lot of the time when that phone rings, you're in the middle of seeing a patient, you're in the middle of war around documenting something, you're in between floors in the hospital where you can't access a phone quickly. And so it often takes five minutes, maybe 10 to get back to the person who called you. And like I said, if it's an emergency, please feel free to bleep me a hundred times in a minute. And after I've seen an unwell patient and then I'm leaving to go do something else, I often tell the nursing staff, if you need me back here urgently, just bleep me twice one after another so that I know that this is an emergency and I'll come straight to the phone. And so I think that's a nice way of kind of helping triage what the level of significance is for something coming through the bleep. Now, the other difficult thing with the bleep I already touched on a little bit, which is that it just constantly distracts you from the task that you're currently doing. So let's say I'm holding the bleep and I'm going through my typical day. If I'm in that MDT or handover in the morning, then I'm getting these bleeps whilst we're in a meeting whilst I'm needing to listen to important information and write down important information. So for me to leave to answer that bleep and come back would be a big kind of loss in the information that I need to take that day. Or I'll be on the warground, we'll be seeing patients, I'll be documenting or we'll be moving in between floors at the hospital or whatever. And so it constantly takes you away from the task that you're doing in order to answer this bleep. And that's why going back to what I said earlier in this video, if you have a float, someone who's kind of sole responsibility is to be in charge of this bleep and answer the calls that come through it, as well as helping out with other tasks throughout the day, it's incredibly, incredibly helpful. Now amongst the F ones on the vascular surgery rotation who are there with me, I think we did a really good job of evening out the responsibility and the workload that comes along with this bleep. We would all offer it to take it from each other at different points in the day. We would always give it to the person who had the least kind of stressful position or things going on in that particular time of the day. I felt like we were really fair with sharing that around evenly. And that felt really good because you knew that if you were struggling and really busy doing something, you could always message the group and say, Hey, would someone be able to take this bleep off of me? I'm really, really stuck. And that was very nice. Now with all the stress and responsibility that's come along in my life with this new job as a doctor, making sure that I keep my mental health in check has been a top priority for me. And I've been doing this with the sponsor of today's video, BetterHelp. If you don't already know, BetterHelp is the world's largest therapy service and it's 100% online. With BetterHelp, you can tap into a network of 30,000 licensed and experienced therapists who are able to help you with a wide range of issues. To get started, you just answer a few questions about your preferences and needs in therapy to let BetterHelp match you with the perfect therapist for you. Then you can talk to your therapist, however it is you feel comfortable, whether that's through text, chat, phone or video call. You can message your therapist at any time and schedule sessions at a time that's convenient for you, which is really, really great for me as a doctor with my continuously changing rota, being able to schedule in sessions at a time that works for me is extremely helpful. And if your therapist isn't a right fit for you for any reason, you can switch to a new one at no additional cost. With BetterHelp, you get the same professionalism and quality that you would expect from in person therapy with a therapist who's custom picked for you with more scheduling flexibility and at a more affordable price. Personally, doing therapy has completely changed my life and I couldn't recommend it more. Click the link in the description to go to betterhelp.com slash karma medic. That's better H E L P dot com slash karma medic to get 10% off your first month back to the video. All right. So we're moving to the bed for this part of the video because this is my favorite part of the video and my favorite part of the whole rotation, which was the surgery. Now guys, when I tell you the surgery in this rotation was incredible. It was incredible. The bread and butter of the procedures on this rotation was cutting off patients limbs either below or above the knee or cutting off their toes. That was the bread and butter. That was the basic stuff that they did on a daily basis. How amazing. And then also some bread and butter was the briding of wounds in surgery that couldn't be done at the bed side either because it couldn't be done under local anesthetic or the infection was probing too deep. And you need to open up more of the of the wound to get in there. That was the bread and butter stuff. I mean, incredible surgery to do as your normal day in and day out. So the toe amputations, I actually only got to take part in one of them. And this was incredibly quick. I think it took about seven minutes or so from knife to skin until it was all said and done. Very, very quick, quite gruesome and brutal chopping off a toe, but it was a really interesting surgery to see. I didn't actually get to do any of the cutting or chopping in that one because it was the first one that I saw. But that's the toe amputations. Now the main surgeries that I was actually a part of throughout my rotation were above knee amputations and below knee amputations. And most of the ones that I took part in were above knee, but I got to see I think two below knee amputations during my time there. Now these were honestly amazing. I mean, this is the type of surgery that I'm most excited about that I think I really want to do is either open surgeries. So open abdominal open thoracic surgery or things like this where you get to see the entire, you know, flesh and wound inside of the body. I'm less a fan of endovascular surgeries or laparoscopic surgery. Although laparoscopic is still interesting because at least you get to see the inside of the body on a screen. But these are surgeries typically where you enter the body through a very small hole either in the radial archery or in the groin in the femoral archery or in another archery. And then you work kind of inside the body with small wires and guided instruments or laparoscopic surgery. We enter the abdomen or the chest cavity with small wounds. And you go in with kind of cameras and these long tools that you can use to see inside the body. So those are minimally invasive procedures. And then you have fully invasive procedures like open abdominal surgery, open heart surgery, things like amputations. That's the stuff I'm really, really excited about. Now in all the surgeries that I got to go to on my time during vascular surgery, I was scrubbed in, I was standing there, you know, doing the things, taking part in the surgery and actually being useful and a part of the team, which was so wonderful compared to a lot of the surgeries I take and part in as a medical student, you may or may not be scrubbed in. And even if you're scrubbed in, you're mostly just watching, but from a closer point of view, maybe getting to do a few things here and there. But on this rotation, what I think the registrars did so well was actually made me feel like I was part of the team. And I was valuable and I was useful being there in the surgery. So a lot of the time these surgeries are done by the surgeon and then an assistant surgeon. And so if there was already a surgeon and an assistant surgeon, plus me, I was kind of helping do all the extra things, which was still very interesting for me to be honest. I loved every single minute of it, but I wasn't as deeply involved. But then when there was the surgeon and I was the assisting surgeon, that was the absolute best because I was actually valuable. I was useful. I was doing the surgery with the head surgeon, which was amazing. So not only was I able to dissect the tissues, you know, all the way starting from the skin down to the subcutaneous tissue, down to the muscle, down to the bone, going through important structures like the saphenous vein that runs down in the leg, identifying arteries and nerves that the surgeons would then tie off and deal with, not myself, all the way to using, you know, a pneumatic bone saw, this big bone saw that would go and you'd be able to cut through someone's tibia or fibula or femur. And then you would grind down that bone saw with a file to get a nice smooth edge. I mean, it was just incredible. And then suturing the muscles on top. Guys, it was amazing. Like I can't describe how it was just incredible. It was incredible. You know, dissecting through all these layers and being able to identify structures that you see in the textbook that you read about in your anatomy classes and that you've heard about so many times, but actually seeing it there in person and seeing how it courses through the body in its natural anatomical place was just amazing. And then yeah, I mean, we had a lot of, you know, really high pressure intense moments and a lot of really relaxed kind of teaching surgery as we were going along, depending on the registrar, why I was with or if there was a consultant present or not and how much and how involved they were, you know, I would either have a lot of responsibility and get to do a lot or not so much. But regardless, whichever surgery I was a part of, I had so much fun story time about my absolute best experience in theater that I've ever had in my life. So I was on a night shift and typically on night shifts, the f ones cover the wards, they deal with the patients upstairs on the wards. They don't really take part in surgery. And so I wasn't expecting to take part in surgery in any way shape or form, but I had been speaking to my vascular registrar who said that a really interesting case was being blue lighted over to the hospital for surgery. And I said to them, you know, if there's any opportunity for me to be involved or if I could come even to see it, I would be really, really grateful. I would love to see this case. And what this case was was an impending rupture of an abdominal aortic aneurysm. So what this is is the aorta, the largest artery in the human body kind of goes up like this and then comes down. You have the thoracic aorta and then the abdominal aorta. The abdominal section of this patient's aorta had an aneurysm, which means a ballooning or stretching of the artery in an abnormal way. So normally it should be a cylinder, but instead there was kind of a big balloon poking out. And this big balloon of the aorta was impending to rupture. So it was due to rupture at any time, which is obviously a very big medical emergency. And something that you don't see very often, which I really, really wanted to be a part of. And so I was going along my night doing my thing. And then I think at about 11pm or maybe midnight, I got the most exciting text I've ever seen in my life. And it was a text from my vascular surgery registrar. And she said, NASA, we need an extra pair of hands in surgery. Come down ASAP. And when I saw that text, can describe how excited I was, I was so happy and so excited that I was going to go down and be part of the surgery. And not only was I going to go see it, I was going to be the extra pair of hands that they needed. So I was going to be involved in a significant way. And I was so excited. So I went to tell the rest of my team, and they very, very kindly took my bleep and they agreed to let me go down to theater whilst they kind of took care of what I was supposed to be dealing with on the wards. Very, very thankful to the SHO who took my bleep during that time. Thank you very much. I was able to take part in probably the coolest thing I've ever seen in my life. So we go down and the surgeons are already scrubbed in and they're like, NASA, NASA scrub in. So I quickly scrub in, get on my gown and my gloves and things and come to the patient's bedside. And they had already opened the abdomen and they were sort of teasing apart the layers around this abdominal aneurysm. So the game plan was to take the abdominal aorta with the big aneurysm in the middle, clamp it on the top and on the bottom, and then insert a graft or a stent. I don't remember which one any surgeons watching can correct me, but basically insert an artificial tube to go in and connect the two parts. So we clamp above and below, we remove the abdominal aneurysm, the diseased part of the artery and then replace it with a graft or stent, which reopens the lumen and allows blood flow to go down. Now the trouble the surgeons were having here is every time they clamped the aorta from the top, it was basically ripping apart. It was such a diseased aorta that every time they clamped it, it was just ripping and tearing and blood was gushing down into the abdomen. And the surgeon would jump in with his hands and just apply pressure. And we were getting to the point where, you know, I was being asked to apply that pressure on the on the aorta to stop it from gushing out with blood. And I'm standing there pressing with the entire strength that my body has. And I was reaching the point where my hands were shaking like this. And I turn to the surgeon, the surgeon, I say, Listen, guys, I've got about, you know, 30 seconds to a minute before I can't press any longer. And so then someone else would take over and they'd apply that pressure. They would try to go down there and get control of the aorta from the proximal side. And we were unable to over and over again. And there were just so many times where I was standing there applying as much pressure as I could down in this patient's abdomen and thinking to myself like, you know, if I let go here or if I slip or if something happens, this patient is just going to bleed out. And it was incredibly high stress and high pressure. And the head surgeon and my registrar who were leading this whole thing, huge props to them. I mean, I hope I am as capable and as calm of a surgeon as they were during that in the future. This was a scenario where the patient almost died several times throughout that night. And in fact, we were getting to the point where we were losing so much of the abdominal aorta was starting to go too high where we couldn't even clip it. And the decision was made to suture the aorta there and close it off entirely and then suture the distal part of the aorta as well and close that off entirely. That means that there's no blood reaching the lower half of the body. So the aorta, you know, comes up and comes down and delivers blood to the rest of the body. So if you cut it over here and you close it, there's no blood going down to the rest of the body. And I was sitting there whilst this was happening and I was thinking to myself, you know, how are we going to resolve this situation? How are we going to deliver blood to the rest of the patient's body if we've closed it up over here? And the solution was an auxiliary femoral femoral graft. So they take the auxiliary artery and pass a lumen from the auxiliary artery underneath the patient's skin all the way down here under over the chest wall, over the abdominal wall and it goes down and inserts into the two common iliacs. And this was just amazing. I mean, I think we were in surgery for maybe four or five hours dealing with that aorta, unable to get control of it when the decision was made to just tie it off and move on to the second part. We took a break for about 20 minutes, 30 minutes, and then went back into the theater and continued the rest of the surgery. So that took the entire night. I think it was maybe eight hours at the operating table or something. It was absolutely crazy and genuinely like the best experience of my life. It was incredible. I can't believe I was able to take part in that. And in such a meaningful way as well, you know, it's the middle of the night, the surgeon and my registrar, they text me and they're like, NASA, we need an extra pair of hands come here ASAP. And I was so happy to go do that. And, you know, play a role in the surgery. It was just, it was incredible. I can't wait to do more surgery in the future. I can't wait to be a surgeon and do this, you know, most days of my life. That was a bit of a tangent, a bit of a ramble. Honestly, I hope my excitement comes across in that. I was so happy doing that and I can't wait to do more in the future. So vascular surgery as a whole, I found to be quite senior led, but nowhere near as much as my current renal rotation, which we'll get into in a future video, but generally still quite senior led on my geriatrics rotation, the previous one where I would be personally responsible for the patient for several days or even weeks in a row, taking histories from them, examining them, making decisions about their treatment and management, following up on those, et cetera. In vascular surgery, it was very much that the juniors were responsible for the computer, just looking up the numbers and the information of stuff that has happened to the patient over the last day or two day. And then the vascular surgeon themselves would see the patient in typical surgical rotation style. So surgical ward rounds are very different to medical ones. Medical ones, you kind of assess the patient holistically from top to bottom, take your time, take a history, et cetera. Surgical ward rounds are very much, you know, if there's nothing going on with the patient, you look at them from the end of the bed. If they look well, then you just say a waiting X or Y scan and you move on. So a lot of the ward round would involve the vascular surgeon just walking around, kind of looking at the patient, seeing if they look okay and moving on or walking up to them saying, Hey, good morning. How are you doing today? And if they say they feel fine, we update them on what we're waiting for or what we're doing and we move on. And even when intervention was needed. So let's say we needed to deprive someone's foot at the bedside, get rid of either dead or necrotic tissue or attempt to clear out some of the pus or infection that was in someone's wound. I found that it was just done very, very quickly, you know, get the job done, do the thing and then move on. And this is quite typical of surgical specialties. I'd say, you know, the stereotype really does hold true. And from my experience, it certainly does hold true. Surgical ward rounds are significantly faster in seeing each of the patients than it would be on a medical ward round. But on this particular rotation, because of the number of patients we had, the ward round was typically very long anyway. So like I said, it was very senior led with the seniors doing most of the patient-related stuff and the juniors like myself doing most of the computer stuff. I'd say except for a few times on the ward where I would actually be able to deprive the patient's foot by bedside with a scalpel, which was really, really cool, or get to suture a bleeding point, a small artery in someone's wound. Generally speaking, I wasn't very much involved in the care of the patient on the ward round. The surgeons would take care of that. The only times on my vascular surgery rotation where I felt like I got a lot of clinical experience, a lot of personal responsibility was out of hours. So on, on call shifts or on nights, things like that, or on the weekends, when there were significantly less staff and us juniors were the first point of call for anything that would go wrong or when patients become unwell throughout the day. So let's say we're doing our ward round and the bleep goes off, I pick it up and someone says, Hey, one of your vascular surgery patients is unwell in X or Y way on a different ward. The registrars and the consultant would just say to me, Okay, go and deal with it. And so, you know, all by yourself, you'd have to go to this other ward, see this unwell patient, assess them, make decisions about them, examine them, et cetera, and then go back and report to your seniors. So we did get good clinical experience and responsibility, but typically in the more high stress scenarios when patients were unwell and we kind of had to deal with things on our own. Of course, if we did need help in a surgical capacity, the surgeons and registrars were there to help us. But if it was pretty much anything medically related, they would just ask us to refer to the specialty that would be able to help or to the part team, the critical care outreach team. And in particularly bad scenarios, the medical registrar. So I did gain quite a lot of experience in dealing with sort of acute emergencies or acutely unwell patients, you know, patients complaining of chest pain who ended up having heart attacks or patients who were unwell because they were septic. What else, you know, these types of events that are typically more high stress for a junior to deal with by themselves. But those are the types of scenarios where we would be expected to go deal and manage the situation on our own, only really asking for help or referring if we needed it. Other than the above, unfortunately, a lot of the job involved just documenting on the computer and falling around the surgeons whilst they moved around at lightning speed, seeing all the patients trying to get everything written down so that we would have a job's plan to work on later. So patient caseload was actually quite interesting for vascular. I'd say for all of the patients, we could generally throw them into three big buckets of their past medical history. The first and most common one was a history of diabetes, typically poorly controlled or uncontrolled diabetes. The second was an extensive smoking history, which of course, as you know, can greatly affect the blood vessels in your body. And then the third was hypertension or high blood pressure, typically poorly controlled or long standing chronic high blood pressure. The diabetes, as you may or may not know, can affect both the small blood vessels in your body and the large ones. And we call this micro and macro vascular disease. So with micro vascular disease, diabetes tends to affect the kidneys, the eyes and the neurons. We call this nephropathy, retinopathy and neuropathy. And then the macro vascular disease commonly affects the large arteries in the body, commonly the coronary arteries or the arteries of the heart, and then also your peripheral arteries going down to the hands and to the feet. Now these types of patients, as a whole, are sick. They are unwell and they are prone to becoming significantly unwell in a short period of time. In comparison to my previous rotation on geriatrics, where I only really saw patients above the age of 70, anywhere between 70 and even 100 sometimes, in vascular surgery, we'd see a much wider range of ages, the youngest probably being around 30 and the oldest being somewhere in the 60 to 70 range. But typically on a daily basis, we'd see everyone, you know, in the 30s, 40s, 50s, 60s, that whole block of age. And that's one of the things that I found particularly interesting about this rotation is how many patients we saw with significant vascular disease who were quite young. Anyone in their 30s, 40s, even up to their 50s, medically speaking, is considered quite a young patient. And to see them with such significant disease, I thought was, you know, quite sad. And it's interesting to think about what those patients could have done or what has happened to them that's led to such significant disease at a young age. But overall, it was very nice to be able to speak to patients who almost always had capacity or almost always able to make decisions for themselves about their health and could tell you their history and what happened with them in the past, what they were feeling at the time, and you know, what had gone on. This was all information you could get directly from the patient, which wasn't always the case in geriatrics. Okay, let's talk about night shifts. So night shifts were very scary, especially for my first set of nights as a brand new F1 doctor. The idea of doing nights is like a fever dream where I'm just hoping that the day never comes. But alas, it did. And I actually vlogged my first set of surgical nights on my channel. You can watch that up over here. It's a video that I think is very informative and one that I'm very proud of. If you're a new doctor who's going to be doing nights, I'd highly recommend watching it. I think it's a really good one. Anyways, so the setup for surgical nights is as follows. There is one F1, me, one SHO, and then one surgical registrar. So the surgical registrar would spend most of their time operating in theater for emergencies overnight or somewhere far away from the wards sleeping and chilling and only coming when we needed them. The SHO would spend most of their time downstairs in A&E, clarking in new surgical admissions and dealing with that. And then myself, the F1, we were responsible for covering the patients on all the wards. Now how this worked is that the F1 on surgical nights would cover vascular surgery, urology, trauma and orthopedics, and general surgery slash colorectal surgery. So what this meant was, myself, me, the F1, was the first line of defense and the first point of call for somewhere around 200 patients plus overnight. Like I mentioned before, vascular surgery would have somewhere between 50, 60, 70 patients. And then each of those other surgical specialties would have the same. And if any member of staff needed to contact someone for help for one of those patients, they would call me. So that's quite daunting, honestly, as it is by itself. And honestly, nights could be really, really stressful and very, very busy. The bleep overnight would go off nonstop. Because like I mentioned, there were 200 plus patients. And if any one of them became sick or unwell, or if the nursing staff needed help about any of those patients, they would call me the one surgical F1 overnight. So most of the time, the first half of my night from about 8pm until midnight would be spent doing the tasks that were outstanding from the day, which would be handed over to me by the surgical F1s in each of those four specialties. And then the second half of the night would largely be dealing with emergencies and situations that arose throughout the night that needed help for patients on the wards. So nights could be extremely stressful. And honestly, often were extremely stressful, especially because any surgery that happens overnight, there's not enough or not as much staff around as there would be during the day. And I would be the first port of call to go see and deal with emergencies and unwell patients overnight. And one of the situations that I remember very, very well that stands out to me whenever I think about nights or when I talk about nights is the following. So on one of my nights, it was about two in the morning or something like that. And I get a call about an unwell patient who's saturating 70% and is choking or aspirating. And normally, people saturate at 94% and above anything between 85 and 94% is pretty bad. Saturating 70% is terrible. On top of that, this patient was aspirating or choking. And this was because they had small bowel obstruction. So an obstruction in their small intestines, which means everything that you consume can't go down through the normal passage and instead is likely to come up and out. The treatment for small bowel obstruction is to place a NG tube down into the stomach and intestines to decompress everything that's built up in there and also to give the patient IV fluids. This particular patient did not want a nasogastric tube and they had refused one throughout the day and they had capacity to do so. And this was documented clearly by the day team. And so he did not have a nasogastric tube. The issue with this and the big risk with this is that you vomit all of the contents that's in there that's building up and then you aspirate or you choke on that same contents that you've brought up. And I had recently seen this on a previous set of nights where the patient died because they vomited and aspirated choked and they died. And so I get a call in the middle of the night to come see this patient who's saturating 70% and has vomited and aspirated because they don't have the NG tube. I go to assess this patient. The first thing that you do in this situation is make sure that the airway is patent or the airway is safe, which in this case it was getting to the point where it might not be. You could audibly hear upper airway secretions when this patient was trying to breathe. They were saturating 70% which is really, really low. And this was just a all around bad situation. So immediately start emergency management, insert an airway adjunct to get the suction to suck out all of the secretions that are at the top of the airway and try and manage this patient's airway whilst doing an ATE assessment which goes through the airway breathing, circulation, disability and extremities. So this was going on and I was managing this by myself at like two or three o'clock in the morning. And it got to the point where I felt that this patient's airway is unsafe and might deteriorate from this point on. And so I called both of my seniors, the SHO and the surgical registrar and told them that I need help immediately. Please come upstairs and help me with this. At the same time as that was happening, a nurse came running up to me saying, Hey, this patient is complaining of chest pain and I think they're having a heart attack. And after a few questions and having a look at their ECG, which is that electrical reading of the heart that I think we talked about before, it was clear to me that this patient was in fact having a heart attack, which is a medical emergency and needs immediate treatment and management and a call to cardiology. So these two situations were happening at the same time. As I was reading the ECG and realizing that this patient is in fact having a heart attack, another nurse comes running up to me saying that a patient has had a fall and hit their head and is bleeding on the ward. And you know, this is one of those nightmare scenarios you never want to end up in with three patient emergencies that all need my attention at the same time. And I was completely alone, very, very stressful, very high pressure. It's just, it's a nightmare of a scenario. You literally never want to be in this position. And thankfully, the most urgent one, which was the patient whose airway was at risk of compromise started to improve. And I managed to settle that scenario and make sure that they were okay. And as my SHO arrived to help kind of manage that situation, I went off to deal with the patient who was having a heart attack, did all the necessary tests and investigations called cardiology, et cetera, et cetera. At the same time, casting an eye on this gentleman who had fallen and had a bleed, telling the nurses how to manage that and you know, place pressure on the wound and make sure they're okay, take their observations, notify me if anything happens whilst I was dealing with this other emergency. And going back to back to back with these three emergencies was just very stressful. I think the whole thing took a couple of hours to sort out. And that's the type of thing that can happen on nights when you don't have as much staff as you would during the day. Whereas, you know, during the day, we might be able to split up all these tasks and get the different relevant teams involved. But overnight, you really have to triage and prioritize, you know, the most at risk patients call the relevant specialties to help you deal with other patients, call your seniors for help to come in. And yeah, that's an example of a very, very stressful set of events on nights. So on one hand, nights can turn out like that, which is really, really unfortunate. But on the other hand, this is where you are, you know, really practicing medicine, really being a doctor, learning how to deal with emergency situations, prioritize, call the relevant specialties, give the appropriate handovers, etc, etc. Whereas a lot of the job during the day was me being on the computer, you know, following the surgeons around whilst they dealt with the patients when you're out of hours on calls on nights. That's when you really learn the skills, I guess, of a doctor and practicing real clinical medicine. I think that's pretty much all I have to say about nights at the moment. If you want to learn or watch more about what it's like to be a doctor on nights, I highly recommend checking the video that I put up. A quick comment on the team that I had surrounding me in vascular surgery, you know, from the bottom of my heart, I really loved them all. Everyone from the consultants of which there were about 10 or 12 to the Regis, which they were about eight, I think, and then all the juniors, all my fellow F1s and the SHO who is working with us, genuinely, I really liked you all. I think we worked very well together as a team. We had a good amount of banter, a good amount of seriousness, a good amount of efficacy and a mindset of working hard and getting everything done. I think we all just honestly gel together and had a very good time on this rotation. Despite how heavy the workload was, despite how stressed we were sometimes, we just all worked together to get the job done. I really felt like every day when I walked into the office, it was me and my family of the vascular team. We were just all tackling the same problem together, helping each other throughout the day. The registrars were also excellent in getting me into theater and getting the other F1s into theater if they wanted. We would scrub in every single time and we were always there helping, you know, holding different surgical instruments, learning how to suture, learning how to dissect with a scalpel, amputating people's limbs using the bone saw. You know, we really were involved and I felt like they treated us like an important member of the surgeries when we went and an important member of the team when we were on the wards. They could easily not have done, but they took the time to do it and I'm very, very thankful for it. And then the fellow F1s that I worked with, you know, we all carried our own weight. They were all very friendly to talk to, easy to get along with, hardworking, efficient, and just more than willing to help whenever they could if they were able to. So honestly, 10 out of 10 team couldn't have asked for anything better. So the workload on vascular surgery was intense. I mean, there's no way around it. There were a lot of patients, a lot of unwell patients, and it was just, you know, high pressure from the moment you start till the moment you finish. And we were constantly working from the second we stepped into the hospital until we left. There were very few low periods where there wasn't a lot going on. He was just constantly trying to get the whole list of jobs done, trying to prioritize and delegate tasks amongst ourselves to make sure we did everything that we needed to. And in fact, on vascular surgery, we spent, you know, over the four month rotation, most of the time when we had our lunch, we ate our lunch at our computers at our desks in the doctor's office, doing jobs as we were eating and taking phone calls and bleeps and things just so that we would be able to finish everything that needed to get done throughout the day. And I mean, even just the normal working hours, the standard day being from eight in the morning until six PM, it's just such a huge chunk of time. And that doesn't include the on call shifts, which are from eight till eight, or nights or weekends or anything like that. And so just the sort of base amount of hours worked was significantly high. It was a very draining job, very tiring. I mean, there was absolutely no energy to come back home and go to the gym or really do anything else useful in my day. Once I got home, I was just so tired, always wanting to rest, always wanting to sleep and feeling like I didn't have enough rest. The days where I was able to go to theater and be off the wards were the best because not only was I not dealing with all of the stress that was happening upstairs, but I was also doing surgery, which is my favorite activity. And so those were the best days, but they were few and far between. I think, like I said, I managed to get to theater maybe eight to 10 times somewhere around there throughout the entire four month rotation. So overall, I'd say vascular surgery patients tended to be quite unwell to begin with. And if they weren't unwell already, then they were very prone to falling off a cliff, as we say, and becoming really unwell really fast. So really, I'd say we dealt with quite a lot of different emergency scenarios with regards to vascular surgery patients. One of the most important ones is assessing someone for an acutely ischemic limb. So this is when you have an acute or short term decrease in blood flow or complete stoppage of blood flow to someone's peripheries to either their hands or their arms or down to their legs and their feet. Now, this is a medical emergency because without blood flow to the peripheries, you get tissue necrosis or tissue death. And then that can eventually lead to someone needing an amputation or they could even die from it if it's not treated appropriately. And so identifying these scenarios and dealing with them appropriately and quickly is incredibly important. So with an acutely ischemic limb where someone loses blood flow to their peripheries like this, it's often due to an embolus. So this is a thrombus which has formed somewhere else and then traveled along the arterial system and gotten clogged or blocked somewhere along the way. In the chronic setting, on the other hand, you can have a slow and gradual buildup of a plaque or a thrombus which builds up over time and then reaches sort of a critical threshold where there isn't enough blood flow going down to the peripheries and the patient gets all the classic signs and symptoms that come along with that. So an acutely ischemic limb commonly presents with what we call the five Ps. So this is a patient's limb that is pulseless, pale, has paristhesia or loss of feeling, has paralysis or inability to move, and pain, typically quite excruciating and significant pain. As serious as the scenario is, it's quite a satisfying clinical examination. You go to assess the patient, they're usually complaining of significant pain down in their limb. You go and feel both limbs like this and you can very obviously feel that one is a lot colder or cooler than the other. If you attempt to feel for the peripheral pulses and they're either not there or very weak and you often get skin changes as well. So color changes going pale because there's no blood flow and so you lose the redness or the warm color of the leg and it becomes white or pale. So if you do make this diagnosis, it requires urgent escalation to one of your seniors because these patients need emergency revascularization or reopening up of the blood vessels where that blockage exists. And if you're unable to do that or they're not a good candidate for that, then the patient might need amputation. If you're starting on vascular surgery or you have this rotation upcoming, I would definitely read about acute limb ischemia, chronic on acute limb ischemia and chronic limb ischemia, definitely helpful to know. The next thing we dealt with quite a lot was heart attacks or myocardial ischemia. Because of the nature of the patients who tend to be admitted under vascular surgery, they have or they tend to have a lot of peripheral arterial disease either due to long-term hypertension, long-term uncontrolled diabetes or long smoking history. So their arterial disease burden is quite high. And this means that complaints of chest pain on the wards were extremely, extremely common. Now when a nurse comes up to you and tells you that a patient is complaining of chest pain or you get a bleep saying that a patient is complaining of chest pain, this is something that you always have to take very seriously because they could be having a heart attack, which is a medical emergency and requires immediate and quick treatment. So learning how to differentiate between cardiac chest pain and non-cardiac chest pain and all the investigations and blood tests that you need in order to decide on that is really, really important. So I'd say one of the things that we spent quite a lot of time doing in vascular surgery was reading people's ECGs. So these are electrical readings of the activity of the heart. It comes out on this piece of paper and you can use it to look to see if someone is having a heart attack and you know, decide from there what you want to do. Now of course, there were a lot of ECGs, which we just didn't know, is this a heart attack, is this not a heart attack? And even after comparing it to previous ones, we were kind of unsure and unable to tell in which case we would need senior support or advice from the cardiology team. So we spent quite a lot of time on the phone with cardiology, asking them about different ECGs and presentations that the patients had. And then of course, probably the most common thing we would see is sepsis from infection in our patients. So a lot of our patients, especially those from the diabetic footran that we talked about before, where patients could have seriously large and gruesome wounds in their feet, you know, open skin breaks, pus, dead and necrotic tissue, very, very malodorous and infection in there. This was very, very common. If you have an open wound on your foot that has all of this pus and infection, you are very prone to getting osteomyelitis, which is an infection of the bone in that area, or you're very likely to have that disease spread from the area that it is in the foot to the rest of the body, into the bloodstream, causing sepsis and bacteremia and all kinds of other problems for the patient. On the other half of our patients, we had all the surgical patients. So those who underwent amputations of their leg, either below or above the knee, they might have had certain digits or toes cut off. And those are wounds which are prone to infection again after surgery. And you know, often enough after surgery patients would develop an infection in their wounds, become septic, become really, really unwell and we would need to deal with them. So off the top of my head, I'd say those are the three kind of most common emergency types situations that we would run into on vascular surgery and ones that I would definitely recommend reading up on becoming a bit familiar with if you're going to start the rotation. One of the most common medical conditions we would come across in vascular surgery is a patient who has uncontrolled diabetes or poorly controlled diabetes. So they lose sensation in their feet or in their peripheries. And then because they can't feel, they don't have the sensation in their foot. If they cut themselves on a piece of glass or if they get, you know, a break in the skin for whatever reason, that can become infected and that can develop into an entirely big problem that they don't even know exists because they can't feel the bottom of their foot. And more than you would expect, patients would come in after weeks and weeks and weeks of a horribly smelling foot of a very poorly looking foot, you know, with infection and pass and maybe gangrene on top of it. They just wouldn't seek medical care for a long, long periods of time. And by the time they get to the hospital, it's come to a stage where it's so bad that it either needs surgical debridement and washing out or revascularization surgery to bring back blood flow down to the foot or, you know, a whole number of other things. But there was a large element of neglect in a lot of these patients that we saw where by the time they presented to the hospital, things had gotten so bad in their wounds. So that was very, very common for us to see an infected wound on someone's foot. And then the other common thing we would see is chronic ischemia. So a patient would have pain in let's say the tip of their big toe, and it would be painful for a couple of days or maybe a couple of weeks. And then they would start to notice that it was becoming black on the end. So this would be dry necrosis. So the blood flow is unable to reach the end of the toe. And it's starting to become black. You're getting tissue death over there. And it would become more and more ischemic up until the point where you had, you know, a whole digit that was just black and effectively mummified, which the body was naturally trying to kind of cut off and get rid of if it stayed dry, then that's good. So that would be dry gangrene or dry necrosis. But if it became wet or boggy or infected, then that would require immediate management. I'd say those are the most common things that we saw. Okay, let's wrap up this video with some concluding thoughts. So overall, I loved my vascular surgery rotation as busy as it was, as stressful as it was, and, you know, as difficult as the rota and as tiring as it was. I honestly thought it was incredible. I felt that, you know, we were constantly working constantly busy doing something important. The surgeries obviously were a highlight for me and I enjoyed them very, very much. I really felt like I was practicing real medicine and doing a lot of hands-on procedures and skills and things, which is something that I didn't get to do in my previous rotation and that I don't do a lot of right now in my current rotation on renal. And that's the part of the job that I honestly enjoyed the most. I think when I talk about my rotation on vascular surgery and I look back on it, I do see it with very rose tinted glasses. And when I get reminded of the realities of what the day-to-day was like and how drained I was and how tired and stressed I was at times, it definitely makes me realize that. But, you know, overall, when I look back on the rotation, what I remember are the highlights, are the things that I really enjoyed where I was in theater, being useful and doing all these incredible things. And then the teamwork, the camaraderie that we had and the efficiency and ability to help each other out when we were each individually stressed or overworked. Overall, I really enjoyed the rotation. So my personal rating for this rotation I think is about a nine out of ten. It was about as good as I could hope, about as fun as I imagined being in theater and doing all those incredible things. I honestly give it a high rating. I think if you're not into surgery and you have no interest in the kind of hands-on procedures or theater time and things like that, then it would probably drop down to something like a six. It's a very intense rotation, a very tiring one. And if you're not interested in the surgery part, then there's not much to look forward to. And so I think it would go a lot lower down. And certainly a lot of my colleagues who are not interested in surgery did not enjoy the rotation very much at all. But the combination of being surrounded by a wonderful team, spending time in theater, cutting off people's limbs as my job, you know, getting paid to be in theater and do these incredible surgeries and procedures, as well as practicing a lot of good clinical medicine and learning how to deal with medical emergencies and high stress situations. Overall for me makes it honestly a really great rotation. And I think one of the better ones that I'm going to have when I look back on my foundation years to anyone interested in surgery, I'd highly recommend ranking it somewhere in your list of jobs when you're applying for foundation training. I honestly really enjoyed it. And that's it for me. That's it for this video. I hope that you enjoyed it. And I hope that you learned something new. If you're going to be joining foundation training, I hope this gives you a bit of an insight into what a surgical specialty job might look like and might help you inform your decisions when ranking your jobs. And if you're not in medicine at all, then you find these videos interesting. Thank you so much for watching. I hope it gives you an insight into what the life of a doctor is like and the types of things that we do on a day-to-day basis. And that's it. Thank you so much for watching. Have a great day. And I'll see you in the next one. Bye bye.